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APPLICATION FOR WELLIPUMP PE PAYML `SXFJOAQUIN COUNTY PUBLIC HEALTH ICES p—cmv m ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON, CA 95202 AUG 2 8 1998 (209)468-3420 SgN,IO�t.�Ul,'V C, WON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUE .. VPUEILI H- 11 o mcg d ��wa P[� (E GmpMb in TrlpRcabl /C! �/C U�AL ,VIC+Fvg APPLICATION 19 HE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.T1118 APPLICATION RS AE'�F�EIPLIANCE WITH SAN JOAQUIN COUNTY D {{RNEN'T TI�TjLEC,�CHAPTER 9-1115..33 AND �THE ESSTANDARDS OF BAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRDNME HEALTH bMAtON. JOB ADORESSUOR APNO_I e4f / 7 0? 5 0 le ✓ `" CITY V -.._ .-_,PARCEL BtZEUAPNI 31/y�✓/S�iF1"t/tfl� Zv. OWNER'S NAME Q t ADDRESS ¢ �f!-- ..2D PHONE N CONTRACTOR J �� ADDRESS �J L1C4 PHONE SUB CONTRACTOR I i� ex ADDRE86 C� �i g LICO PHONE I TYPE OF WELL/PUMP, ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL II ❑ OTHER ^^ ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL• J ❑New❑Repel- H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMPI ❑ OUT-OF-SERVICE WELL ❑ OEOPHYSICAL WELL/ .COY SOIL BORING 8 ❑DESTRUCTION: INTENDED USE TYPE OF W CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ©OPEN BOTTOM DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASINO D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACKUBtZE TYPE OF CASIN018TEELIPVC DIA.OF WELL CASINO D ❑ PUBLICAUUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND HAMS E ❑ MONI70RINO GROUT SEAL PUMPED: ❑Yee ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Yr [IN. S APPROX.DEPTH_ /t 7"_` -� LOCKING CHESTER BOX/STOVE PPE S PROPOSED CONITRUCTIONMAILLINO METHOD: MUD ROTARY AIR ROTARY AUGER CARLE OTHER l��P I HMSY CERTIFY THAT 114AVE PREPAREO THIS APPLICATION AND THAT THE WOW WILL BE DONE 1N ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REOULATIONS OF THE RAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING-'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA,' CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIER THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL OURS IN ADVANCE FOR ALL REBURIED IMSTECTIONS AT 12091440-3423. COMPLETE DRAWING AT LOWER AREA PRDVtDEb. �y Wr Signed X Tltle� /S -Date PLOT FLAN ID.ew to Beale)Beale_'I. I( 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. // EXPANSION OF SEWAGE DISPOSAL SYETEMS, 3, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WRHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOIMNG PROPERTY. V 77 .. .>�vG�rwG.. cfl .. .. p, , 1 DEPARTMENT USE ONLY